010 - hand flaps
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LOCAL HAND FLAPS
BY JEROME D. CHAO, MD, JOSEPHINE M. HUANG, MD, AND THOMAS A. WIEDRICH, MD
Wounds of the hand continue to be a challenge for the hand surgeon. The repairof hand wounds has evolved from the simple, such as allowing primary closure,to the complex, such as free tissue transfer. This evolution has occurred because ofbetter understanding of the vascular supply to the skin of the hand along with the
development of improved, more sophisticated surgical technique. Our review of theliterature has shown numerous local hand flaps that have stood the test of time.Though lower on the reconstructive ladder, these flaps continue to aid the hand
surgeon in dealing with soft tissue losses of the hand. It would be impossible tocatalogue all local hand flaps in this article. Thus, we present many of the mostuseful and historic flaps, which we feel should be a part of every hand surgeons
armamentarium.Copyright 2001 by the American Society for Surgery of the Hand
T
he practitioner of hand surgery usually has an
algorithm for the closure of hand wounds that
involve soft tissue losses. That algorithm in-cludes the use of a combination of primary wound
healing, grafts, local flaps, distant flaps, and free tissue
transfers. Many hand wounds can be closed by simple
measures. When more complex wounds present them-
selves, hand surgeons generally rely on a few favorite
local tissue coverage options. The advent of free tissue
transfer has made this means an attractive way to close
the most complicated wounds. A review of the liter-
ature has shown a great number of local hand flaps
that have stood the test of time and can be called on
as effective tools to aid the hand surgeon in dealingwith soft tissue losses of the hand. These flaps can
generally be divided into flaps for the fingertips, dig-
its, thumb, palmar hand, and dorsal hand.
RANDOM FLAPS
The principles that govern the use of random flaps
can be used throughout the hand and fingers.
Generally these flaps are of greater use over the dorsal
surfaces, but in the correct circumstances they can be
applied to the palmar aspect of the hand as well. A
form of transposition flap with which the hand sur-
geon is familiar is the Z-Plasty (Fig 1). The Z-plasty
is of great value when dealing with skin contractures
over the volar aspects of the hand, especially contrac-tures that cross the normal volar skin creases. When
the Z-plasty technique is used, all the limbs of the
Z-plasty should be of equal length. The most common
angle Z-plasty is the 60 Z-plasty. Theoretically,
there will be a 75% increase in length of the long axis
of the Z-plasty. The greatest theoretical gain mathe-
matically comes from a 90 Z-plasty, but this is not
clinically feasible.
In the first web space, a 4-flap Z-plasty can be used.
Four 60 equilateral triangles are arranged as shown
From the Division of Hand Surgery, Northwestern University Med-ical School, Chicago, IL.Address reprint requests to Thomas A. Wiedrich, MD, 448 EastOntario Street, Suite 500, Chicago, IL 60611.
Copyright 2001 by the American Society for Surgery of the Hand1531-0914/01/0101-0003$35.00/0doi:10.1053/jssh.2001.21783
JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND VOL. 1, NO. 1, FEBRUARY 2001 25
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(Fig 2) and are transposed as shown to increase length
theoretically one and a half times. Another series of
transposition flaps of use in the first web space is theso-called jumping-man flap. The flap receives its name
based on the pretransposition drawing. The flap is
transposed as shown (Fig 3). This flap does more to
deepen the web space than it does to increase length.
Another transposition flap often used is the Lim-
berg Flap.1 This flap is occasionally referred to as the
rhomboid flap. In this flap, the defect is turned into a
rhomboid. A line is extended that equals the height of
the rhomboid. This line is then extended parallel to
one of the sides as shown (Fig 4). The flap is elevated
and transposed into the defect. The wound can then be
primarily closed.Rotational flaps are used frequently over the dor-
sum of the hand and fingers (Fig 5). These flaps are
designed to allow a defect to be closed by dividing the
tension of closure over a much larger surface area. To
design this flap the surgeon outlines the defect, de-
cides which adjacent area provides the most tissue,
and designs a curved incision, which will allow rota-
tion into the defect when the flap is elevated. The use
of a small back cut or creation of a Burows triangle
can help gain some small extra rotation.
One technique that can help in certain instanceswhen extra tissue is needed and delay of the flap is
warranted is the use of tissue expansion. This can be
done safely over the dorsum of the hand and can allow
the surgeon to gain extra tissue, which has excellent
vascularity because of the delay phenomenon.
LOCAL FLAPS FOR FINGERTIP WOUNDS
The decision on which method of wound closure
should be used depends entirely on the geometry
of the wound and on local wound factors. The main
factors leading to the use of flaps are (1) exposed vitalstructures such as bone, tendon, and nerve; (2) a
wound not suitable for healing by secondary intention
or grafting; or (3) a need for soft tissue padding. The
following are many of the options for closure of fin-
gertip wounds.
V-Y Advancement Flap (Atasoy Flap)
The V-Y advancement flap was first described by
Tranquilli-Laeli2 in 1935 and was reported first in the
FIGURE 1. Z-plasty. A standard Z-plasty with 60angles. Thetheoretical gain in length is 75%. (Reprinted with permis-sion.28)
FIGURE 2. Four-flap Z-plasty. A 4-flap X-plasty in which allmeasurements are equal. The theoretical gain in length is150%. (Reprinted with permission.29)
FIGURE 3. Jumping-man flap. The 5-flap Z-plasty. (Reprintedwith permission.30)
FIGURE 4. Limberg flap. The rhomboid flap of Limberg isshown. (Reprinted with permission.30)
26 LOCAL HAND FLAPS CHAO ET AL
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United States by Atasoy and colleagues in 1970.3 The
indications for this flap are transverse or dorsal oblique
amputations with exposed bone and sufficient nail bed
support and length. This flap is contraindicated in
volar oblique tip amputations.
This flap is generally described as having the base of
the volar triangle as the distal edge of the amputationand the apex occurring at the distal interphalangeal
(DIP) crease (Fig 6). It has also been described to
extend proximal to the DIP crease without sequelae.
Many drawings show the base of the flap to be narrow,
but it is helpful and in fact desirable to make the base
extend from radial midaxial line to ulnar midaxial
line. This will increase the number of vessels flowing
into the flap. The flap is mobilized by gently dividing
the fibrous septa, which attach the skin to the deeper
structures. The deep margin of the flap is cut directly
off the periosteum and the flexor sheath. The neuro-
vascular structures should be preserved. With careful
and complete mobilization, approximately 1 cm of
advancement can be obtained. After advancement the
wound is closed as a Y; hence the name V-Y advance-
ment. This flap provides excellent sensation as well as
soft tissue coverage.
Bilateral Triangular Advancement Flap
(Kutler Flap)
Kutler4 described a double lateral advancement flap
in 1947. Shepard5 has modified this original tech-
nique. This flap has been included in most treatises
describing fingertip coverage. Although it is probably
described far more than it is actually used, there is the
occasional patient in whom this flap is useful. The
Kutler flap has been condemned primarily because
generally the flap does not allow for advancement of
more than 3 to 4 mm, and there is a sagittal scarplaced on the tip of the finger. Classically, this flap is
indicated in patients with transverse or volar oblique
amputations. In actuality, the patient in whom this
flap is useful generally will have an amputation where
there is more tissue on the radial and ulnar margins of
an amputation and exposed distal phalanx.
As in the V-Y advancement flap, the bases of the
triangles are the cut edges of the wound, this time the
radial and ulnar aspects of the wound (Fig 7). The
dorsal edges of the 2 flaps begin 1 to 2 mm volar to
the edge of the fingernail and extend volarly 7 to 8
mm. The apex of the flap sits just distal to the DIP
crease. Soft tissues are mobilized as with the V-Y
advancement flap. It is not necessary to close the skin
centrally over the fingertip as long as there is good soft
tissue closure over the exposed distal phalanx. The
wound is then closed as a Y, again as in the V-Y
advancement flap.
Oblique Triangular Flap
With the description of the volar V-Y advancement
flap and the lateral V-Y advancement flap, Ven-
FIGURE 5. (A) Rotational flap and outline of planned skin incisions. (B) Rotational flap. Excision of Burrows triangle facilitatessliding of the flap toward the defect. (Reprinted with permission.28)
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kataswami and Subramanian described the obliquetriangular flap (Fig 8) in 1980.6 As suggested in its
name, establishing an oblique triangle in essence cre-
ates this flap. This flap has the advantage in that it can
be used for palmar/oblique amputations and it can be
converted to a neurovascular island pedicle flap if
more advancement is required than can be obtained
with a standard elevation of the flap.
The flap is outlined beginning at the midlateral
line and is extended proximally 2.5 times the diam-
eter of the wound. The opposite midlateral line is
identified, and an oblique incision is made from thedistal midlateral wound edge to the proximal mar-
gin of the midlateral incision. Care is taken to
preserve the neurovascular bundle near the straight
midlateral incision. With elevation, the flap is ad-
vanced, inset, and then closed in a V-Y fashion. If
additional mobilization is necessary, the flap is then
converted to a neurovascular island flap (described
below) and advanced further into the defect. Clo-
sure of the donor site with a full-thickness skin
graft may be necessary.
FIGURE 6. V-Y advancement flap. (A) Skin incision andmobilization of triangular flap. (B) Advancement of flap. (C)Closure of defect with V-Y technique. (D) V-Y advancementflap. Advancement of triangular flap. (Parts A, B, and Creprinted with permission.31)
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Cross-Finger Flap (Transdigital Flap)
When there is a loss of greater that one third of thevolar tissue of the fingertipespecially with exposed
flexor tendon, joint, or bonemore tissue is required
than with advancement-type flaps. The cross-finger
flap is a popular option under these circumstances (Fig
9). This technique was first described by Cronin7 in
1951 and is still widely used. Multiple fingertips can
be covered simultaneously. Diseases that limit joint
motion (such as arthritis and Dupuytrens disease) are
contraindications. Patients with impaired digital cir-
culation are also considered contraindications.
There are multiple donor choices for this flap. The
middle finger can be used to cover the thumb, index,or ring fingers. The ring finger can be used to cover
the long or small fingers. Once the donor digit has
been selected, the recipient finger is debrided. The
flap from the donor digit should be designed slightly
larger than the recipient defect. The flap is rectangular
and is based on the midlateral line closest to the
recipient digit. The plane of dissection is just dorsal to
the paratenon. Care must be taken not to injure the
paratenon during elevation. The donor site is covered
with a full-thickness skin graft, and the flap is sutured
to the recipient site. The digit is held together either
with a splint or with Kirschner wires. At 10 days to
3 weeks, the flap is separated from the donor site and
the remainder of the flap is inset.
Variations of the cross-finger flap have been de-
scribed in which dorsal nerves have been included and
anastomosed to the digital nerve stump with reported
improvement in sensation. A reverse cross-finger flap
has also been described by Atasoy8 in which the
epidermis and papillary dermis are divided and the
reticular dermis and subcutaneous tissue have been
used to cover the dorsum of an adjacent digit (Fig 10).
The skin flap is laid back into place over the donor
site. A full-thickness graft is then placed on the
reverse flap.
Hueston Flap
Hueston9 described a lateral palmar advancement
flap to cover the tip of the amputated finger (Fig 11).
Souquet10 described a similar flap (Fig 12). The dif-
ference between the 2 flaps is that the Hueston flap
includes only the neurovascular bundle at the base of
the flap, whereas Souquets flap includes both neuro-
vascular bundles. Both flaps are technically rotation
advancement flaps. In the Hueston flap the longitu-
FIGURE 7. Bilateral triangular advancement flap (Kutler). (A)Designing and developing 2 triangular flaps on the midlateralaspect of the distal phalanx. (B) Incisions are deepened intothe subcutaneous tissue. (C) Flaps are advanced and su-tured by converting V to Y. (Redrawn from Germann.32)
FIGURE 8. Oblique triangular flap. (A, B) Designing the flapon the side of the finger and incision. (C) Raising the flapbased on a digital neurovascular bundle. (D, E) Advancingthe flap and closing the defect with the V to Y technique.(Redrawn from Germann.32)
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dinal incision is made volar to the neurovascular bun-
dle, and in the Souquet flap the incision is made dorsal
to the bundle. The incision is generally 2 to 3 cm
long. A transverse back cut is made across the volar
aspect of the finger, and the flap is elevated off the
flexor tendon sheath. Next, the flap is elevated and
rotated into the defect. There will generally be a
triangular defect proximally, and this must be closed
with a skin graft.
Thenar Flap (Thenar H-Flap)
The thenar flap is used to cover defects and preserve
length in tip injuries to the index and long fingers
(Fig 13). This flap is not used to cover defects in the
ring and small fingers. Contraindications to this flap
are similar to that for the cross-finger flaps.
The donor site is found by taking the tip of the
injured index or ring finger and placing it against the
thenar eminence. It is helpful to draw a circle around
FIGURE 9. Standard cross-finger flap. (A) The donor site is grafted. (B) Flaps raised on hinges. (C) Flaps inset and donor
defects covered with full-thickness skin graft. (D) Divided and healed result. (Part A reprinted with permission.32
)
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the area of contact. An H is drawn that is slightly
larger than the outlined circle. The transverse portion
of the H is made at the distal-most portion of the
circle. The H is incised, and flaps in the subcutaneous
plane are elevated. The ends of the flaps are sutured to
the respective dorsal and volar fingertips and to each
other along the lateral margins. This method effec-
tively advances the edges of the donor defects to one
another. The digit is left attached to the donor site for
approximately 2 weeks, and the flap is then divided by
using the proximal flap to cover the fingertip and the
distal flap to fill in the donor site.
Dorsal Middle Phalangeal Finger Flap
Hirase and colleagues11 described a potentially sen-
sate flap to cover the fingertip from the dorsum of the
long finger (Fig 14). The dorsal middle phalangealfinger flap has been described to be used for the tips of
any finger except the thumb. This flap requires that
digital Allens test be normal in the donor digit.
The flap is outlined exactly as would be a cross-
finger flap. However, the flap is incised as an island,
and the base is taken volar enough to include a
vascular bundle. The dorsal sensory branch of the long
finger is taken with enough length proximally to
perform an anastomosis with the recipient digital
nerve. The vascular pedicle is dissected proximally
either to the level of the common digital artery oreven to the superficial arch if needed. Once the dis-
section is complete, the island flap is transferred to the
recipient site by means of an incision from the origin
of the pedicle to the recipient defect. The wound is
closed after the neural anastomosis is carried out.
Finally, a full-thickness skin graft is used to close the
donor defect. Joshi12 describes a similar flap but uses
it exclusively on the donor digit.
Homodigital Bipedicle Island Advancement Flap
The homodigital bipedicle island advancement flap
is useful for defects over the volar aspect of the fingerin the area of the middle phalanx. OBrien13 and
Snow14 originally described an advancement flap for
injuries to the tip of the thumb. This flap was also
applied to the other digits. After a wave of initial
enthusiasm, the use of the flap decreased because of
problems with flexion contractures of the digits and
the risk of dorsal skin loss. Whereas the thumb has
relatively independent volar and dorsal circulation,
the dorsum of the fingers have circulation more de-
pendent on the volar blood supply. That said, there is
FIGURE 10. Reverse cross-finger flap. (A) Design of the flap.(B) Raising a full-thickness skin flap. (C) Raising a full-thick-ness subcutaneous flap in the opposite direction. (D) Suturingthe reversed flap along the defect. (Redrawn from Ger-mann.32)
FIGURE 11. Hueston flap. (A) Outline on the radial border ofthe thumb. (B) Dissection anterior to pedicle. (C) Flap inplace. (Reprinted with permission.34)
FIGURE 12. Souquet flap. (A) Outline. (B) Dissection. (C)Flap in place. (Reprinted with permission.34)
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still some value for the neurovascular island flap in the
digits. Although the flap is generally described to
cover fingertip injuries, it can also be used to cover
defects of the volar middle phalanx. Damage to the
digital arteries is a contraindication to the use of this
flap. Advancement of 10 to 15 mm can usually be
achieved.
A rectangular incision is made from midlateral line
to midlateral line (Fig 15). The flap is elevated, and
the radial and ulnar neurovascular bundles in the flap
are preserved. The flap is elevated off the flexor sheath
with care not to expose the flexor tendons. By using
gentle traction, the neurovascular bundles are pre-
served, and the flap is advanced with the aid of gentle
FIGURE 13. Thenar flaps can be based (A) proximally, (B) distally, or (C) both. The donor site is closed primarily. (D) A Thenarflap. (Parts A, B, and C reprinted with permission. 32)
FIGURE 14. Dorsal middle phalangeal finger flap. Illustration of the steps for elevation. (Reprinted with permission.35)
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dissection of the neurovascular bundles. The flap is
then inset, and the donor defect is covered with a
full-thickness skin graft.
Turkisk Flap (C-Ring Cross-Finger Flap)
The Turkisk flap can be used to cover relatively
large defects of the volar and dorsal skin of the fingers
(Fig 16). It is sometimes used to cover degloved finger
stumps. An abnormal digital Allens test is a contra-
indication for the use of this flap.
The flap is based on one of the digital vascular
bundles and can be based distally or proximally. The
digital nerve is not included in the flap. Although the
flap is based on the dorsum of the finger, it can include
volar skin of the area of the middle phalanx. As with
many of these flaps, the plane of dissection is just
superficial to the paratenon, with care taken to leave
the paratenon intact. Although a small skin bridge is
left intact to protect the digital artery, the flap can be
made into an island flap to allow for more flap mo-
FIGURE 15. Homodigital bipedicle island advancement flap (OBrien flap). (A) Outline. (B) Elevation of flap and proximaldissection of the pedicle. (C) Flap in place. (D) Outline of flap drawn adjacent to defect. (E) Flap sutured in place distally withfull-thickness skin graft covering secondary defect. (Parts A, B, and C reprinted with permission. 34)
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bility. The flap is then inset into the recipient defect.
For a degloving injury the flap can be sewn to itself to
create a cap over the degloved segment defect. A
full-thickness skin graft is used to cover the donor
site. Flap division is carried out at 10 to 14 days.
Reverse Vascular Pedicle Digital Island Flap
The reverse vascular pedicle digital island flap was
described in 1989 by Lai et al15 and then in 1990 by
Kojima et al.16 Although most local coverage of the
finger relies on antegrade arterial flow, this flap func-
tions on the digit much as the reverse radial forearm
flap does on the hand and arm. A positive digital
Allens test is a contraindication to the use of this flap.
An island of skin is outlined at the base of the
affected finger (Fig 17). The flap is centered on one ofthe digital arteries. The flap is elevated from a prox-
imal to distal direction and the digital vessel is ligated
proximally. Elevation of the flap continues in a distal
direction. Digital vessels are kept in the soft tissues of
the flap. Once the island has been elevated, the digital
vessel along with a cuff of perivascular fat is taken to
include the venae commitantes. The vessels are dis-
sected distally to the level of the midmiddle phalanx.
The flap is then rotated into the recipient site and
sutured in place. The donor site is skin grafted.
FLAPS FOR COVERAGE OF THE VOLAR THUMB
Many of the flaps that have been described for use
in covering the thumb were originally described
to aid in thumb reconstruction. With the advent of
microvascular toe-to-thumb transfer, some of these
flaps are used with less frequency. There still are
specific indications, however, for which knowledge of
these flaps is of value.
Moberg Volar Advancement Flap
Moberg17 first described the thumb advancementflap in 1964 as a means to preserve length in the
distally amputated thumb. There are certain reasons
why this flap is an attractive option for the closure of
wounds for the tip of the thumb. First, the flap
vascular supply is easily identified at the end of the
wound. Second, the blood supply to the dorsal aspect
of the thumb is quite independent of the volar blood
supply. Third, as opposed to the fingers, a resultant
flexion contracture of the thumb generally leaves the
thumb in a functional position.FIGURE 16. Steps for elevation and inset of C-ring cross-finger
flap (Turkisk flap.) (Reprinted with permission from the ChristineM. Kleinert Institute for Hand and Microsurgery, Inc.32)
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Mobergs thumb advancement flap is used when
there are amputations through the distal phalanx. The
neurovascular bundles are identified and incisions are
made on either side of the thumb, dorsal to the
bundles (Fig 18). Dissection is carried down to the
flexor sheath, and the flap is elevated off the flexor
sheath. Usually the proximal metacarpal phalangeal
crease of the thumb is the proximal margin of the
dissection. The flap is then advanced to cover the
defect. If necessary, the interphalangeal joint of the
thumb can be flexed. This flap can be converted into
a bipedicle island flap to gain greater length if neces-sary. The resulting defect can be skin grafted with a
full-thickness skin graft.
Neurovascular Island Pedicle Flap
Before free tissue transfer for thumb reconstruction,
the neurovascular island pedicle flap was used to at-
tempt to provide sensation to an insensate thumb
reconstruction. There were those surgeons who were
very enthusiastic about the flap, but there was diffi-
culty in that the brain would still interpret sensory
information as coming from the donor digit. A po-
tential solution was to suture the digital nerve from
the proximal thumb to the divided distal nerve in the
flap. The problems with this, however, are incomplete
sensory recovery and possible damage to the vascular
structures in the pedicle. Currently, the only indica-
tion for the use of this flap is the scarred and sensitive
thumb with ischemic pain.
The donor site is usually the ulnar aspect of the
long or ring finger. Most surgeons prefer the long
finger, because the pedicle is longer. It is essential to
perform a digital Allens test to the donor finger aswell as to the adjacent finger before considering this
flap. Attention is first turned to the recipient site. The
scarred and sensitive area of the thumb tip is excised,
and the defect is created and measured. The ulnar
digital nerve is found and is prepared for anastomosis.
The flap is then outlined on the donor digit and is
incised, preserving the neurovascular bundle (Fig 19).
The bundle is traced proximally as far as the superficial
arch. As much perivascular fat as possible is kept with
the bundle. The common digital vessel with the adjacent
FIGURE 17. Steps for elevation and inset of reverse vas-cular pedicle digital island flap. (Reprinted with permis-sion.36)
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finger is divided, and the vessel is taken back to the
superficial arch. A subcutaneous tunnel is created to the
recipient site, and the island flap is passed into therecipient site. The flap should not be twisted or be tight
in any way. The nerve transposition is then performed. A
full-thickness graft is used to cover the donor site.
Holevich Racquet Flap
Holevich18 described the racquet flap in 1963 as a
means of restoring sensibility to the thumb by using
tissue from the dorsum of the hand, especially for
chronic median nerve lesions. His flap used portions of
the superficial branch of the radial nerve to substitute
for the lost sensation over the volar thumb. This flap
can be used to add soft pliable tissue to contractures or
defects of the first web space.A proximally based flap is created over the base of
the second metacarpal (Fig 20). The flap includes 2 to
3 branches of the dorsal sensory branch of the radial
nerve. The flap is extended distally to the level of the
metacarpal head. Because the second dorsal intermeta-
carpal artery is included in the flap, the flap can be
made quite narrow (2 to 3 cm) relative to its length.
The flap can be easily elevated from the extensor
tendons. An incision is made from the donor site to
the defect on the thumb. The flap is then inset into
FIGURE 18. Moberg flap. (A) A Z-plasty at the base of the flap facilitates mobilization. (B) Volar flap advanced distally to coverdefect. (C) Advancement of flap. (D) Clinical appearance after graft has healed. (Part A reprinted with permission.28)
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the recipient site. The donor defect can sometimes be
closed primarily, but if tension of the closure is too
great, a full-thickness graft can be used to close the
donor site.
Foucher Kite Flap
As a logical extension of the previous flap, Foucher
and Braun19 in 1979 improved on the Holevich flap
by undertaking a detailed description of the anatomy
of the first dorsal metacarpal artery. By defining theanatomy so precisely, they were able to devise an
island flap from the dorsum of the index finger to the
thumb. This flap is an excellent choice when there is
a need for soft tissue coverage on the thumb. The flap
has also been used when there is trophic scarring of
the thumb or a sensory deficit of the thumb that
cannot be managed in other ways. The flap is contra-
indicated when the soft tissue tunnel is so scarred that
the resulting tight tunnel would jeopardize circula-
tion of the flap.
The flap is outlined over the dorsum of the proxi-
mal phalanx of the index finger (Fig 21). The flap can
include the skin overlying the metacarpophalangeal
joint if necessary. An incision is then made in the
dorsal first web space, and dissection is carried down
to the first dorsal metacarpal artery, which arises from
the radial artery. With a very complete dissection, a
pedicle of 7 to 8 cm can be created. The flap is thenincised and elevated at the level of the paratenon from
a distal to proximal direction. Fascia adjacent to the
second metacarpal along with adjacent fat are kept
intact along the course of the vessels. A subcutaneous
tunnel is created from the donor site to the recipient
site, and the flap is brought through, with care taken
not to kink or twist the pedicle. The dorsal proximal
phalanx is covered with a full-thickness skin graft.
Annular Flap
Goumain et al20 described the tetrapedicled ho-
modigital island flap in 1972 (Fig 22). This flap isused especially when sensory tissue is required to
cover defects of the thumb, particularly at the level of
the proximal phalanx, but occasionally it has been
used also for the ring finger. The flap is contraindi-
cated when there has been disruption of one or both
neurovascular bundles.
A circular area is outlined approximately 2 cm
proximal to the edge of the soft tissue defect. Only the
skin and subcutaneous tissue are dissected. The neu-
rovascular bundles are freed proximally to allow the
FIGURE 19. Neurovascular island pedicle flap. The island isoutlined to include the blood supply and nerve. (Reprinted
with permission.37
)
FIGURE 20. Holevich flap. (A) Skin defect on thumb. (B)Elevation of flap. (C) Flap in place with donor defect skingrafted. (Reprinted with permission.34)
FIGURE 21. Foucher kite flap. (A) Skin defect on thumb. (B)Elevation of flap. (C) Placement of flap throught subcutane-ous tunnel. (Reprinted with permission.34)
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annular flap to advance distally 10 to 12 mm. The
distal wound can thus be closed, and the proximal
wound is either grafted or allowed to heal by second-
ary intention.
COVERAGE OF DEFECTS OF THE HAND AND
PROXIMAL FINGERS
With defects of the hand, often the tissues im-
mediately adjacent to the wound are of insuf-
ficient quantity to close the wound. In some instancesrecruitment of the local tissues of the forearm are
necessary to gain adequate coverage of the wound. The
skin and subcutaneous tissues of the forearm are an
excellent match in quality and depth to cover wounds
of the hand.
Dorsal Island Digital Flap (Axial Flap)
Lister21 has advocated and described a flap from the
dorsal proximal phalanx of a digit that can be used to
cover adjacent defects of the finger and hand. This flap
usually covers defects of the ipsilateral or adjacent
digit to the level of the proximal interphalangealjoint. This flap is based on the dorsal digital artery of
the adjacent finger.
The flap is outlined over the dorsum of the proxi-
mal phalanx of the donor digits (Fig 23). Flaps up to
3 3 cm can easily be raised. The dorsal digital artery
is identified. It generally arises as a branch of the
proper digital artery but may also arise from the dorsal
metacarpal artery. When the vessel is identified, it is
preserved with the dorsal regional venous drainage.
The flap is then elevated as an island from distal to
proximal, preserving the extensor paratenon. With
full elevation of the flap, the flap is rotated into
position, with care taken to avoid kinking of the
pedicle. The donor defect is closed with a full-thick-
ness skin graft.
Fillet Flap
The fillet flap should always be considered when
one is dealing with injuries requiring amputation of a
digit. The soft tissues of a digit can sometimes be
salvaged by fillet of the bony structures from the soft
tissue and skin. The flap is useful for covering palmar
or dorsal hand wounds. In designing the fillet flap, the
pulp tissue is usually discarded (Fig 24). A longitu-
dinal incision is made according to the location of the
defect to be closed. An incision is made approximately0.5 cm proximal to the nail fold. The phalanges and
tendons are excised. The flap is placed into the defect
with the base of the flap as a hinge point.
Radial Forearm Flap/Radial Forearm Fascial
Flap
Chang and Wang22 published their results with a
retrograde flap based on the radial artery in 1980. This
flap has proven to have wide use in the hand and even
fingers to cover relatively large defects. The flap has also
been popular as a free tissue transfer. Occasionally, the
flap can be used as a fascial flap as well if skin and
subcutaneous tissue are not needed at the recipient site.
The flap is contraindicated in instances where, either
congenitally or because of trauma, the palmar arch is
incomplete. There is discussion as to whether or not to
reconstruct the radial artery after flap transfer, but this
does not appear to be necessary most of the time.
The flap is designed along the longitudinal axis of
the radial artery (Fig 25). There is some variation in
designing the flap to allow for varying lengths of the
FIGURE 22. Annular flap. (A) Amputation with protrudingbone. (B) Dissection and advancement. (C) Distal closure.(Reprinted with permission.34)
FIGURE 23. Dorsal island digital flap (axial). The dorsaldigital artery may arise either from the proximal digital arteryor from the dorsal interosseous metacarpal artery. (Reprintedwith permission.38)
38 LOCAL HAND FLAPS CHAO ET AL
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pedicle. Thus, the flap can be designed to cover either
proximal or distal hand wounds. More distal defects
will require more proximal skin paddles. Dissection is
first carried out through the distal forearm to expose
the radial artery and the venae comitantes. When the
distal border of the flap is encountered, the flap is
dissected first from its ulnar border. The dissection
continues to the pedicle. The plane of dissection is
superficial to the palmaris longus and flexor carpi
radialis. Just radial to the flexor carpi radialis, the
pedicle will be found lying within a septum. The
pedicle and the perforators, which supply the flap, are
FIGURE 24. Fillet flap. (A) Third metacarpal and digit with extensive injury. (B, C) Dissection of soft tissue from skin. (D, E) Useof skin for coverage of defect on hand dorsum. (Reprinted with permission.39)
LOCAL HAND FLAPS CHAO ET AL 39
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kept contiguous with the flap. Dissection is then
begun over the radial aspect of the flap, and the
dissection continues radially until the septum isreached. The dissection then proceeds under the radial
vascular bundle, and muscular branches are ligated
and divided. The radial artery is divided at the level of
the proximal margin of the flap, and the dissection
continues distally. When the flap and pedicle are
adequately dissected distally, the flap is rotated, with
care taken not to kink the radial artery. The flap and
pedicle can be brought into a defect either by gener-
ous tunneling or by using an incision to connect the
distal pedicle incision to the recipient site. A tunnel is
generally preferred over the radial wrist because of the
superficial radial nerve. Care should be taken over the
ulnar wrist in the area of the dorsal sensory branch ofthe ulnar nerve. The donor site is then covered with a
split-thickness skin graft.
When a radial forearm fascial flap is to be used, a
longitudinal or zigzag incision is used throughout the
forearm. The skin and subcutaneous tissue are ele-
vated, leaving the antebrachial fascia intact. The flap
is designed on the fascia, and the dissection proceeds
as with the standard reverse radial forearm flap. The
donor site is closed primarily, and the fascia is covered
with a split-thickness skin graft at the recipient site.
FIGURE 25. Radial forearm flap. (A) Flap outlined. (B) Dissection. (C) Inset. (D) Flap covering traumatic amputations with lossof soft tissue, syndactylizing the long and ring fingers. (E) After maturation of graft and division of long and ring fingers. (F) Thekey point in raising a radial forearm flap is recognizing the level of the septum containing the radial artery and its septocutaneousperforators. BR, brachioradialis; FCR, flexor carpi radialis; FDS, flexor digitorum superficialis; PL, palmaris longus; R, radius;RA, radial artery; U, ulna. (Reprinted with permission.40)
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Posterior Interosseous Forearm FlapThe posterior interosseous forearm flap was de-
scribed by Penteado, Masquelet and Chevrel23 as well
as by Zancolli and Angrigiani.24 This flap is another
retrograde flap that is based on the posterior interosse-
ous artery (PIA). Defects of the first web space,
thumb, dorsal hand to the level of the proximal in-
terphalangeal joints, palm, and anterior wrist are po-
tentially covered by this flap. Significant injuries to
the wrist are contraindications to this flap as is any
other condition that may cause PIA thrombosis.
Flap design is carried out by drawing a line from
the lateral epicondyle to the ulnar styloid with theelbow held at 90 of flexion (Fig 26). This line ap-
proximates the septocutaneous axis of the flap. The
PIA arises at the junction of the proximal to middle
thirds of this line. Along the course of the PIA there
are 7 to 14 cutaneous perforators, which supply the
skin and fascia. The most proximal perforator arises
close to the proximal/middle third junction. The cen-
ter of the flap should be located distal to this perfo-
rator. The PIA anastomoses with the dorsal wrist
arcade 2 cm proximal to the end of the drawn axis
line. Dissection is begun at this point to ascertainintegrity of the PIA. Technically, a flap 6 to 7 cm
wide can be raised, but defects greater than 4 cm in
width are difficult to close primarily.
The radial incision is created first, and a subfascial
dissection is carried ulnarly. By retracting the extensor
digiti quinti proprius, extensor indicis proprius, and
extensor digitorum communis radially, as well as the
extensor carpi ulnaris ulnarly, the septum containing
the PIA and venae comitantes can be identified. Mus-
cular branches of the PIA are ligated and divided. Care
must be taken to avoid injury to the posterior in-
terosseous nerve, which lies radial to the vessels. Dis-section continues proximally to the main septal per-
forator (most proximal perforator). The artery is
separated from the posterior interosseous nerve. The
vessels are ligated proximal to the main perforator to
the flap. Next, the ulnar border of the flap is elevated,
and the pedicle including the septum is released from
the ulnar shaft. The flap and pedicle are dissected
proximally until enough length of the pedicle is ob-
tained to rotate into the defect. The vessels cannot be
kinked at the rotation point, and the most distal
FIGURE 26. (A) Posterior interosseous forearm flap. Land-marks: the epicondyle, the distal radioulnar articulation, andthe straight line that joins them. The origin of the posteriorinterosseous artery is located at the junction of the proximaland middle third of this line. The center of the flap should bebased distal to this point. (B) Loss of small finger and ulnarside of hand because of injury. (C) Flap inset into defect.(Part A reprinted with permission.34)
LOCAL HAND FLAPS CHAO ET AL 41
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vessels can be rotated 2 cm proximal to the distal end
of the initial axis line.
Dorsal Ulnar Artery FlapBecker and Gilbert25 described a flap based on the
dorsal ulnar artery in 1992 (Fig 27). This flap can be
used to cover defects of the dorsal or palmar hand.
To construct this flap, an incision is made 2 cm
proximal to the pisiform. The flexor carpi ulnaris is
retracted to reveal the origin of the dorsal branch of
the ulnar artery, which arises 2 to 5 cm proximal to
the pisiform. The flap is then centered along the axis
of the ulna with the palmaris longus as the volar limit
and the extensor digitorum communis to the ring
finger as the dorsal limit of the dissection. The length
of the flap is variable and designed to fit the defect.
The rotation point of the flap is 2 to 4 cm from the
pisiform, depending on the origin of the dorsal branch
of the ulnar artery. The flap is elevated from proximal
to distal. When the dorsal branch of the ulnar artery
is reached, the flap can be rotated and inset. The donor
site is covered with a split-thickness skin graft.
Retrograde Radial Forearm Fascial Flap
Weinzweig et al26 described the retrograde radial
forearm fascial flap in 1994 (Fig 28). Some additional
clinical applications were discussed by Braun et al27 in
1995. This flap is unlike the other radial forearm flap
in that the radial artery is left in situ. Essentially, this
flap is a distally based turnover flap of the volarforearm fascia. Vascularity of the flap comes from
distal perforating vessels of the radial artery. This flap
can be used to cover defects of the volar and dorsal
hand.
The design of the flap is such that the flap should
minimally be 2 to 3 cm wide. The pivot point is
generally 5 to 8 cm proximal to the radial styloid. In
addition, the flap needs to be designed to be larger
than the defect it is to fill. A gentle S-shaped incision
is made over the volar forearm. Skin flaps are elevated
just deep to the hair follicles. Branches of the radialand lateral antebrachial cutaneous nerve are identified
and freed from the subcutaneous tissue. Once the skin
flaps are elevated to expose the area of flap desired, the
subcutaneous tissue and fascia are incised and elevated
in a proximal to distal direction. Dissection ends at
the pivot point, and the flap is turned over or rotated
into position. Care needs to be taken to avoid undue
tension on the flap.
There are many different problems in wound
coverage because of the many different wounds that
FIGURE 27. Dorsal ulnar artery flap. (A) Anatomy of the dorsal ulnar artery: 1, muscular branch; 2, osseous branch to thepisiform; 3, cutaneous branches (ascending and descending). (B) Elevation of the flap. (Reprinted with permission. 34)
42 LOCAL HAND FLAPS CHAO ET AL
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the hand surgeon will encounter. Working know-
ledge of a number of local coverage options will aid the
hand surgeon in dealing with these sometimes vexing
wounds.
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